ANSI Claims
Adj Code ANSI Claims Adjustment Code Description
ConnectiCare
EX Code ConnectiCare EX Code Description
01 Deductible Amount LN
CHARGES APPLIED TO CALENDAR YEAR OSTOMY SUPPLY/EQUIPMENT DEDUCTIBLE
01 Deductible Amount T5
CHARGES APPLIED TO CONTRACT YEAR DEDUCTIBLE
01 Deductible Amount M5
CHARGE APPLIED TO DME CALENDAR YEAR DEDUCTIBLE
01 Deductible Amount LK
CHARGES APPLIED TO CALENDAR YEAR DISPOSABLE SUPPLY DEDUCTIBLE
01 Deductible Amount LJ
CHARGES APPLIED TO CALENDAR YEAR DME DEDUCTIBLE
01 Deductible Amount L4
CHARGES APPLIED TO CALENDAR YEAR DEDUCTIBLE
01 Deductible Amount D2
THIS CHARGE APPLIED TO THE CALENDAR YEAR DEDUCTIBLE
01 Deductible Amount D6
CHARGES APPLIED TO CALENDAR YEAR DEDUCTIBLE
02 Coinsurance Amount O2
COINSURANCE AMOUNT HAS BEEN APPLIED TO CAL YEAR OUT-OF-POCKET
02 Coinsurance Amount K8
CHARGES APPLIED TO OUT OF POCKET MAXIMUM
02 Coinsurance Amount 6H
CHARGES APPLIED TO IN-NETWORK CALENDAR YEAR OUT-OF-POCKET.
02 Coinsurance Amount L6
CHARGES APPLIED TO CALENDAR YEAR OUT-OF-POCKET
02 Coinsurance Amount E6 COINSURANCE AMOUNT HAS BEEN APPLIED
02 Coinsurance Amount T7
CHARGES APPLIED TO CONTRACT YEAR OUT-OF-POCKET
04
The procedure code is inconsistent with the modifier
used or a required modifier is missing. M9
MODIFIER 22 DOES NOT APPEAR APPROPRIATE BASED ON REVIEW OF DOCUMENTATION 04
The procedure code is inconsistent with the modifier
used or a required modifier is missing. OT
BILATERAL IS INHERENT IN THIS CPT CODE, RESUBMIT 1 UNIT WITHOUT MODIFIER 04
The procedure code is inconsistent with the modifier
used or a required modifier is missing. A0
DENIED - PLEASE RESUBMIT WITH MODIFIER APPROPRIATE FOR MIDLEVEL PROVIDER 05
The procedure code/bill type is inconsistent with the
place of service. CE
CC - DENIED - DIAGNOSIS AND PROCEDURE COMBINATION NOT VALID
05
The procedure code/bill type is inconsistent with the
place of service. 0W
CI - PROCEDURE CODE ISN'T PAYABLE FOR THIS LOCATION
05
The procedure code/bill type is inconsistent with the
place of service. N2
DENIED - SERVICES RENDERED NOT COVERED IN THIS PLACE OF SERVICE.
05
The procedure code/bill type is inconsistent with the
place of service. OP
DENIED - PROCEDURE NOT COVERED IN THIS PLACE OF SERVICE
05
The procedure code/bill type is inconsistent with the
place of service. 9Y
DENY-NOT ALLOWED IN OFFICE LOCATION, MEMBER NOT LIABLE
05
The procedure code/bill type is inconsistent with the
place of service. IV
LOCATION CODE AND PROCEDURE CODE DO NOT MATCH, PLEASE RESUBMIT CLAIM 05
The procedure code/bill type is inconsistent with the
place of service. 4K
CI - TECHNICAL SERVICES NOT PAYABLE TO MD PROVIDERS FOR THIS LOCATION 05
The procedure code/bill type is inconsistent with the
place of service. 4C
LOCATION DOES NOT MATCH SERVICES ON FILE-PLEASE RESUBMIT CORRECT CODING 05
The procedure code/bill type is inconsistent with the
place of service. ZJ
CLAIM DENIED. PROVIDER MUST RESUBMIT WITH VALID DRG NUMBER.
05
The procedure code/bill type is inconsistent with the
place of service. A7
DENY, USE 99213 FOR OFFICE, 99431 FOR INPATIENT
06
The procedure/revenue code is inconsistent with
the patient's age. BU
CC - PROCEDURE OR DIAGNOSIS NOT VALID FOR MEMBER'S AGE
06
The procedure/revenue code is inconsistent with
the patient's age. CA PROCEDURE NOT VALID FOR MEMBER'S AGE
07
The procedure/revenue code is inconsistent with
the patient's gender. BY
PROCEDURE IS NOT VALID FOR MEMBER'S GENDER
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
07
The procedure/revenue code is inconsistent with
the patient's gender. BS
CC - PROCEDURE OR DIAGNOSIS NOT VALID FOR MEMBER'S GENDER
09 The diagnosis is inconsistent with the patient's age. BX
MEMBER'S AGE IS NOT VALID FOR SECONDARY DIAGNOSIS
11 The diagnosis is inconsistent with the procedure. UB DENIED - PLEASE RESUBMIT AS URGENT CARE 11 The diagnosis is inconsistent with the procedure. I3
PER CFC IPA, PROCEDURE LEVEL NOT VALID FOR DIAGNOSIS
11 The diagnosis is inconsistent with the procedure. 95
INCONSISTENT/INVALID
DIAG/PROCEDURE/MODIFIER/DRG. RESUBMIT CORRECTED CLM
11 The diagnosis is inconsistent with the procedure. 4H
CI-INCONSISTENT/INVALID DIAGNOSIS - RESUBMIT CORRECTED CLAIM
13 The date of death precedes the date of service. 3D
DENIED - SERVICE POSTDATES MEMBERS DEATH
15
Payment adjusted because the submitted
authorization number is missing, invalid, or does not
apply to the billed services or provider. FY THE AUTHORIZATION NUMBER IS NOT ON FILE. 15
Payment adjusted because the submitted
authorization number is missing, invalid, or does not
apply to the billed services or provider. 9C
DATE OF SERVICE IS NOT WITHIN THE DATE RANGE OF THE AUTHORIZATION
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate D0
DENIED - RESUBMIT WITH DRUG NAME AND DOSAGE OR CORRECT HCPCS CODE
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate IU
PLEASE RESUBMIT SUPPLIES WITH APPROPRIATE HCPCS CODE
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate B8
MORE INFO NEEDED-PLEASE SUBMIT DETAIL SHEET W/ D.O.S. FOR PART. HOSP PRG
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate JK
DENIED- PLEASE SUBMIT A COPY OF THE PURCHASE INVOICE.
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate HO
DENIED-OFFICE NOTES NEEDED FOR
CONSIDERATION OF BENEFITS ON THIS CLAIM.
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate SE
CC - PLEASE SUBMIT CLINICAL DOCUMENTATION FOR REVIEW
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate RD
DENIED-REFERRING PHYSICIAN CANNOT BE IDENTIFIED ON CLAIM
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate 93
PLEASE RESUBMIT WITH COMPLETE PROVIDER INFORMATION
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate NR
REFERRING PROVIDER INFO FROM REFERRAL NEEDED
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate FN
MORE SPECIFIC/CORRECTED BILLING
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate 97
CORRECTED BILLING INFO.IS REQUIRED. PLEASE CALL 1-800-828-3407.
16
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever
appropriate 53
PLEASE SUBMIT CLINICAL DOCUMENTATION FOR REVIEW
17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 5A
DENIED-CLINICAL DOCU. IS ILLEGIBLE AND THEREFORE CONSIDERED NOT DONE.
17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 59
BENEFITS WILL BE RECONSIDERED UPON RECEIPT OF REQUESTED DOCUMENTATION
17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever
appropriate. RX
CLAIM WILL BE RECONSIDERED UPON RECEIPT OF REQUESTED DOCUMENTATION
17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever
appropriate. UG
DENIED - PLEASE RESUBMIT WITH APPROPRIATE URGENT CARE ID NUMBER
17
Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 3E
DENIED - ER/URGENT CARE - QUESTIONNAIRE REQUESTED WAS NEVER RECEIVED
18 Duplicate claim/service. 36 DENIED - DUPLICATE CLAIM.
18 Duplicate claim/service. HE
DENIED-ORIGINAL CLAIM SUBMISSION WAS PREVIOUSLY DENIED
18 Duplicate claim/service. 16 DENIED-DUPLICATE CLAIM
18 Duplicate claim/service. 0Q CI - DENIED-DUPLICATE CLAIM
18 Duplicate claim/service. HD
DENIED-ORIGINAL CLAIM SUBMISSION IS PENDING FURTHER REVIEW
19
Claim denied because this is a work-related injury/illness and thus the liability of the Worker's
Compensation Carrier. 31
DENIED-INFORMATION INDICATES CLAIM QUALIFIES FOR WORKER'S COMPENSATION. 20
Claim denied because this injury/illness is covered
by the liability carrier. KZ PLEASE FORWARD TO APPROPRIATE CARRIER
21
Claim denied because this injury/illness is the
liability of the no-fault carrier. 68 CHARGE WAS APPLIED TO NO-FAULT BENEFIT. 23
Payment adjusted because charges have been paid
by another payer. 22
MEMBERS ALTERNATE COVERAGE IS SECONDARY
23
Payment adjusted because charges have been paid
by another payer. 23
MEMBERS ALTERNATE COVERAGE IS UNAVAILABLE
24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed
care plan. 08
AMOUNT ALLOWED BASED ON PROVIDER'S CAPITATED SERVICE CONTRACT
24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed
care plan. 28
SERVICE INCLUDED IN PROVIDER'S CAPITATED SERVICE CONTRACT
24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
24
Payment for charges adjusted. Charges are covered under a capitation agreement/managed
care plan. NE
CAPITATED SERVICES BY NEW ENGLAND EYE CARE
26 Expenses incurred prior to coverage. CN
DENIED - THE CONTRACT IS INELIGIBLE AT THE TIME OF SERVICE.
27 Expenses incurred after coverage terminated. GY
DENIED - THE GROUP IS INELIGIBLE DURING AUTHORIZATION PERIOD.
27 Expenses incurred after coverage terminated. 65
DENIED-SERVICE DATE BEYOND PREM PD TO DATE PLUS GRACE PER FOR DIR PAY GR 27 Expenses incurred after coverage terminated. HA
DENIED - THE SUBSCRIBER IS INELIGIBLE AT THE TIME OF SERVICE.
27 Expenses incurred after coverage terminated. GW
DENIED-THE CONTRACT IS INELIGIBLE DURING AUTHORIZED PERIOD.
27 Expenses incurred after coverage terminated. VL
CCI NO LONGER ADMINISTERS THIS PLAN. CONTACT YOUR EMPLOYER.
27 Expenses incurred after coverage terminated. CS
DENIED - THE GROUP IS INELIGIBLE AT THE TIME OF SERVICE.
27 Expenses incurred after coverage terminated. NW
THIS GROUP HAS TERMINATED, SUBMIT ALL CLAIMS TO YOUR BENEFITS OFFICE
27 Expenses incurred after coverage terminated. 39
DENIED - PATIENT IS NOT ELIGIBLE ON CLAIM DATE OF SERVICE.
27 Expenses incurred after coverage terminated. JZ
CLAIM NOT ELIGIBLE FOR PAYMENT - THIS GROUP HAS TERMINATED.
27 Expenses incurred after coverage terminated. GU
DENIED-THE MEMBER IS INELIGIBLE DURING AUTHORIZED PERIOD.
27 Expenses incurred after coverage terminated. 64
DENIED-SERVICE DATE BEYOND PREM PD TO DATE PLUS GRACE PER FOR COBRA GRPS 27 Expenses incurred after coverage terminated. GX
DENIED-THE DIVISION IS INELIGIBLE DURING AUTHORIZED PERIOD.
27 Expenses incurred after coverage terminated. CP
DENIED - THE DIVISION IS INELIGIBLE AT THE TIME OF SERVICE.
29 The time limit for filing has expired. 30
RECEIVED PAST FILING LIMIT - PARTICIPATING PROVIDER CANNOT BILL MEMBER
29 The time limit for filing has expired. B2
DATES OF SERVICE PRIOR TO 1/1/92 CANNOT BE PROCESSED ON AMISYS
29 The time limit for filing has expired. 0A
DENIED-CLAIM SUBMITTED PAST FILING LIMIT. PAR PROVIDER CANNOT BILL MBR.
29 The time limit for filing has expired. P8 DENIED CLAIM SUBMITTED PAST FILING LIMIT 30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or
residency requirements. WR
SERVICES ARE NOT PAYABLE UNTIL 91ST DAY OF CONFINEMENT
30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or
residency requirements. C4
DENIED-GROUP/INDIVIDUAL NON PAYMENT OF PREMIUM
30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or
residency requirements. PC DENIED-MEMBER DID NOT SELECT A PCP
30
Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or
residency requirements. C3
DENIED-OVERAGE DEPENDENT VERIFICATION HAS NOT BEEN RECEIVED
31
Claim denied as patient cannot be identified as our
insured. CR
DENIED - THE GROUP DOES NOT HAVE A GROUP-SPAN RECORD.
31
Claim denied as patient cannot be identified as our
insured. CM
DENIED - THE CONTRACT RECORD IS NOT ON FILE.
31
Claim denied as patient cannot be identified as our
insured. CT
DENIED - NO DIVISION-SPAN RECORD EXIST FOR MEMBER'S DIVISION#.
31
Claim denied as patient cannot be identified as our
insured. CQ DENIED - THE GROUP RECORD IS NOT ON FILE.
31
Claim denied as patient cannot be identified as our
insured. CO
DENIED - THE DIVISION RECORD IS NOT ON FILE.
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
31
Claim denied as patient cannot be identified as our
insured. 91
MEMBER ID NUMBER WITH ORIGINAL CLAIM IS NOT ON FILE.
31
Claim denied as patient cannot be identified as our
insured. FT MEMBER IS NOT ON FILE.
31
Claim denied as patient cannot be identified as our
insured. GZ
DENIED - THE SUBSCRIBER'S RECORDS COULD NOT BE FOUND.
32
Our records indicate that this dependent is not an
eligible dependent as defined. OB
DENIED - DEPENDENT NOT ELIGIBLE FOR SERVICES
34
Claim denied. Insured has no coverage for
newborns. C6
NEWBORN HAS NOT BEEN FORMALLY ADDED, PLEASE CALL CUSTOMER RELATIONS
35 Lifetime benefit maximum has been reached. SC
CHIRO FEE SCHEDULE MAXIMUM PER DAY HAS BEEN MET-MEMBER MAY NOT BE BILLED 35 Lifetime benefit maximum has been reached. 70
LIFETIME ALLERGY TESTING MAX EXHAUSTED --MEMBER CANNOT BE BILLED.
35 Lifetime benefit maximum has been reached. PT
PT FEE SCHEDULE MAXIMUM PER DAY HAS BEEN MET-MEMBER MAY NOT BE BILLED 35 Lifetime benefit maximum has been reached. 6D
DENIED - EARLY INTERVENTION SERVICES LIFETIME MAX EXHAUSTED
35 Lifetime benefit maximum has been reached. 81
DENIED-BENEFIT LIFETIME MAXIMUM EXHAUSTED
35 Lifetime benefit maximum has been reached. 14
DENIED-BENEFIT LIMITS HAVE BEEN EXCEEDED
35 Lifetime benefit maximum has been reached. 13
DENIED-BENEFIT LIMITS HAVE BEEN EXCEEDED
35 Lifetime benefit maximum has been reached. PB
CONTRACT DAILY MAXIMUM HAS BEEN MET-MEMBER CANNOT BE BILLED
35 Lifetime benefit maximum has been reached. 15
DENIED-BENEFIT LIFETIME MAX.EXCEEDED MEMBER CANNOT BE BILLED.
38
Services not provided or authorized by designated
(network/primary care) providers. BO REFERRING PROVIDER IS NOT INPLAN. 38
Services not provided or authorized by designated
(network/primary care) providers. TR
DENIED. TRANSPLANTS REQUIRE PRE-AUTHORIZATION. MEMBER MAY BE BILLED. 38
Services not provided or authorized by designated
(network/primary care) providers. NA DENIED-SERVICES ARE AVAILABLE IN PLAN 38
Services not provided or authorized by designated
(network/primary care) providers. K5 DENY SERVICES NOT AUTHORIZED
38
Services not provided or authorized by designated
(network/primary care) providers. ND
DENIED-PRIOR AUTHORIZATION REQUIRED FOR MEDICAL EQUIPMENT/SUPPLIES. 38
Services not provided or authorized by designated
(network/primary care) providers. K7
DENY UNAUTHORIZED NON PARTICIPATING PROVIDER MEMBER MAY BE BILLED 38
Services not provided or authorized by designated
(network/primary care) providers. MB
PRIOR AUTH REQUIRED IN AN OUTPATIENT SETTING - MEMBER CANNOT BE BILLED 38
Services not provided or authorized by designated
(network/primary care) providers. R9
SERVICES DENIED, NO AUTHORIZATION OR PRE-CERTIFICATION RECEIVED
38
Services not provided or authorized by designated
(network/primary care) providers. 8F
CLAIM DENIED. REQUIRED REFERRAL NOT RECEIVED. MEMBER MAY BE BILLED. 38
Services not provided or authorized by designated
(network/primary care) providers. RF
PAYMENT REVERSED, NON-REFERRED SERVICES, MEMBER MAY BE BILLED 38
Services not provided or authorized by designated
(network/primary care) providers. PO NO AFFILIATION WITH PTPN AFTER 9/30/98 38
Services not provided or authorized by designated
(network/primary care) providers. 83
AN ADMISSION AUTHORIZATION IS NOT ON FILE.
38
Services not provided or authorized by designated
(network/primary care) providers. 3Y
DENIED-NO PRIOR AUTHORIZATION RECEIVED-MEMBER CANNOT BE BILLED
38
Services not provided or authorized by designated
(network/primary care) providers. 6F
CLAIM DENIED. REQUIRED REFERRAL NOT RECEIVED. MEMBER MAY BE BILLED. 38
Services not provided or authorized by designated
(network/primary care) providers. US
MEDICAL RECORDS & EXPLANATION NEEDED IN ORDER TO PROCESS UNAUTH SERVICES
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
38
Services not provided or authorized by designated
(network/primary care) providers. 6G
CLAIM DENIED. REQUIRED REFERRAL NOT RECEIVED. MEMBER MAY BE BILLED. 38
Services not provided or authorized by designated
(network/primary care) providers. 3W
DENIED - ANESTHESIA PROCEDURE REQUIRED PRE-AUTH - IN NETWORK PROVIDER
38
Services not provided or authorized by designated
(network/primary care) providers. 3U
DENIED - LAB PROCEDURE REQUIRED PREAUTH - IN NETWORK PROVIDER 38
Services not provided or authorized by designated
(network/primary care) providers. 17
DENIED-INPATIENT/PROCEDURE REQUIRE CERTIFICATION.
39
Services denied at the time
authorization/pre-certification was requested. G0 THIS SERVICE DENIED AFTER MEDICAL REVIEW
39
Services denied at the time
authorization/pre-certification was requested. H6
CC - SERVICE DENIED BASED ON CLINICAL CODING REVIEW
39
Services denied at the time
authorization/pre-certification was requested. 49 DENIAL BASED ON MEDICAL REVIEW
39
Services denied at the time
authorization/pre-certification was requested. 19
DENIED-INPT/PROCEDURE CERTIFICATION DENIED
39
Services denied at the time
authorization/pre-certification was requested. 7I
DENIED NOT MEDICALLY NECESSARY - MEMBER MAY BE BILLED
39
Services denied at the time
authorization/pre-certification was requested. UP DENIAL UPHELD - PER IPA MEDICAL DIRECTOR
39
Services denied at the time
authorization/pre-certification was requested. UQ DENIAL UPHELD - PER CCI MEDICAL DIRECTOR
39
Services denied at the time
authorization/pre-certification was requested. JI
CC - PROCEDURE DENIED AFTER CLINICAL DOCUMENTATION REVIEW
39
Services denied at the time
authorization/pre-certification was requested. 2C
SERVICES DENIED AFTER MEDICAL REVIEW - MEMBER CANNOT BE BILLED
40
Charges do not meet qualifications for
emergent/urgent care. 58
DENIED-DOC SUBMITTED DID NOT REFLECT URGENT/EMERGENT NATURE OF PROCEDURE 40
Charges do not meet qualifications for
emergent/urgent care. JD DENIED-NON COVERED URGENT CARE VISIT
40
Charges do not meet qualifications for
emergent/urgent care. 38
DENIED-INAPPROPRIATE USE OF EMERGENCY ROOM BASED ON CLAIM INFORMATION. 42
Charges exceed our fee schedule or maximum
allowable amount. MR
DENIED - LIMIT FOR MULTIPLE SURGERIES HAS BEEN REACHED
42
Charges exceed our fee schedule or maximum
allowable amount. 0V
CI - PAYMENT HAS BEEN REDUCED BY USE OF THIS MODIFIER
42
Charges exceed our fee schedule or maximum
allowable amount. L1
THE MAXIMUM PAYABLE FOR THIS BENEFIT HAS BEEN REACHED.
42
Charges exceed our fee schedule or maximum
allowable amount. 73
MAXIMUM AMOUNT HAS BEEN PAID FOR THIS SERVICE
42
Charges exceed our fee schedule or maximum
allowable amount. J5
FEE SCHEDULE DAILY MAXIMUM HAS BEEN MET- MEMBER CANNOT BE BILLED
45
Charges exceed your contracted/ legislated fee
arrangement. J8
INCLUDED IN UNITED RESOURCE NETWORK CONTRACTUAL RATE
45
Charges exceed your contracted/ legislated fee
arrangement. TA CASE AGREEMENT-TRANSPLANT GLOBAL FEE
45
Charges exceed your contracted/ legislated fee
arrangement. 2D
PROVIDER NOT CONTRACTED FOR THIS SERVICE - MEMBER MAY NOT BE BILLED 45
Charges exceed your contracted/ legislated fee
arrangement. 46
DENIED-SERVICES EXCEED PROVIDER CONTRACT.MEMBER CANNOT BE BILLED. 45
Charges exceed your contracted/ legislated fee
arrangement. AJ
PROVIDER CONTRACT EXCEEDED-MEMBER CANNOT BE BILLED
45
Charges exceed your contracted/ legislated fee
arrangement. AZ PROCEDURE IS INCLUDED IN PER DIEM RATE
45
Charges exceed your contracted/ legislated fee
arrangement. 5P
AMOUNT EXCEEDS CAPITATED SERVICES CONTRACT - MEMBER CANNOT BE BILLED 45
Charges exceed your contracted/ legislated fee
arrangement. E0
INCLUDED IN CASE RATE - MEMBER CAN NOT BE BILLED.
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
45
Charges exceed your contracted/ legislated fee
arrangement. YY
MAXIMUM CONTRACT AMOUNT HAS BEEN PAID FOR THIS SERVICE.
45
Charges exceed your contracted/ legislated fee
arrangement. 75
PROVIDER CONTRACT EXCEEDED-MEMBER CANNOT BE BILLED.
45
Charges exceed your contracted/ legislated fee
arrangement. GL
INCLUDED IN GLOBAL PT FEE - MEMBER CANNOT BE BILLED
45
Charges exceed your contracted/ legislated fee
arrangement. LM
MAXIMUM CONTRACT AMOUNT HAS BEEN PAID FOR THIS SERVICE
45
Charges exceed your contracted/ legislated fee
arrangement. TB
INCLUDED IN CASE AGREEMENT TRANSPLANT GLOBAL-MEMBER CAN NOT BE BILLED
45
Charges exceed your contracted/ legislated fee
arrangement. KX PAYABLE ONLY WITH LEVEL I & II TREATMENTS
45
Charges exceed your contracted/ legislated fee
arrangement. E9
MODALITIES ARE INCLUDED IN THE ERN CASE RATE- MEMBER CANNOT BE BILLED
46 This (these) service(s) is (are) not covered. WC
FIRST 91 DAYS OF CONFINEMENT ARE NOT PAID BY CONNECTICARE FOR WESLEYAN 46 This (these) service(s) is (are) not covered. B3 THE BENEFIT HAS NOT BEEN PURCHASED 47
This (these) diagnosis(es) is (are) not covered,
missing, or are invalid. 7H
DENIED - TMJ IS NOT COVERED UNDER YOUR PLAN.
49
These are non-covered services because this is a routine exam or screening procedure done in
conjunction with a routine exam. R8
ROUTINE FOLLOW-UP CARE IN URGENT CARE/WALK-IN IS NOT COVERED 49
These are non-covered services because this is a routine exam or screening procedure done in
conjunction with a routine exam. 9G
ROUTINE CARE NOT COVERED OUT OF NETWORK
50
These are non-covered services because this is not
deemed a `medical necessity' by the payer. 3H
DENIED - AMBULANCE (NOT MEDICALLY NECESSARY)
50
These are non-covered services because this is not
deemed a `medical necessity' by the payer. TH
NOT A COVERED SERVICE-MEDICAL NECESSITY GUIDELINES BEING DEVELOPED 50
These are non-covered services because this is not
deemed a `medical necessity' by the payer. I1
PER CFC IPA, DENIED-SERVICE NOT
MEDICALLY NEC BASED ON CLM INFORMATION 50
These are non-covered services because this is not
deemed a `medical necessity' by the payer. 54
DENIED-PROCEDURE CONSIDERED COSMETIC IN NATURE. NOT A COVERED BENEFIT.
50
These are non-covered services because this is not
deemed a `medical necessity' by the payer. 47
DENIED-PROC DOES NOT MEET CRITERIA OF MED NEC PROG.PT MAY NOT BE BILLED. 50
These are non-covered services because this is not
deemed a `medical necessity' by the payer. 48
DENIED-SERVICES NOT MEDICALLY
NECESSARY BASED ON CLAIM INFORMATION. 50
These are non-covered services because this is not
deemed a `medical necessity' by the payer. 57
DENIED-THIS PROCEDURE DOES NOT APPEAR TO BE MEDICALLY NECESSARY
51
These are non-covered services because this is a
pre-existing condition PI
DENY,SERVICES RELATED TO A PRE-EXISTING CONDITION.
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
billed. 94
REFERRING PROVIDER ID NUMBER IS INVALID - MEMBER CANNOT BE BILLED
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
billed. BL
REFERRING PROVIDER WAS NOT EFFECTIVE AT TIME OF SERVICE
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
billed. R1
DENIED-REFERRING PHYSICIAN WAS NOT ON CLAIM OR WAS NON-PARTICIPATING
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
billed. BR
REFERRING PROVIDER NO LONGER PARTICIPATING WITH CONNECTICARE 52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
billed. JQ
DENIED-PROVIDER SPECIALTY CAN NOT DISPENSE DME
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
billed. IX
DENIED-REFERRING PROVIDER IS NOT A PARTICIPATING PROVIDER.
52
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
billed. JN
DENIED - PROVIDER CANNOT DISPENSE DME OR SUPPLIES
54
Multiple physicians/assistants are not covered in
this case . 55
CC - ASSISTANT MD IS TYPICALLY NOT REQUIRED FOR THIS PROCEDURE 54
Multiple physicians/assistants are not covered in
this case . 0Z
CI - ASSISTANT MD IS TYPICALLY NOT REQUIRED FOR THIS PROCEDURE 55
Claim/service denied because procedure/treatment is deemed experimental/investigational by the
payer. FQ
DENIED - PROCEDURE IS
EXPERIMENTAL/INVESTIGATIONAL. 59
Charges are adjusted based on multiple surgery
rules or concurrent anesthesia rules. AI
AMBULATORY SURGERY PAID ACCORDING TO MEDICARE GROUPINGS
59
Charges are adjusted based on multiple surgery
rules or concurrent anesthesia rules. JX
CC - INFORMATIONAL ONLY, PROCEDURE PROCESSED THROUGH OUR CODING SOFTWARE
59
Charges are adjusted based on multiple surgery
rules or concurrent anesthesia rules. 07 PRICED PER ANESTHESIA CALCULATIONS. 59
Charges are adjusted based on multiple surgery
rules or concurrent anesthesia rules. PH SURGEON'S REIMBURSEMENT FEE REDUCED 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 9F
BENEFITS REDUCED TO COINSURANCE RATE - REFERRAL OF SERVICE WAS REQUIRED. 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 3X
DENIED - ANESTHESIA PROCEDURE REQUIRED PREAUTH - OUT OF NETWORK PROVIDER 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 41
DENIED-HOSPITAL ADMISSION REQUIRES PRE-AUTHORIZATION.
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 42
DENIED - NO PRIOR AUTH/REFERRAL RECEIVED-MEMBER CANNOT BE BILLED 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. L8 CHARGES PAID AT 50% RATE 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 3F
DENIED - UNAUTHORIZED DIALYSIS OUT OF PLAN
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 63
BENEFITS REDUCED BY 50% - PRIOR AUTHORIZATION IS REQUIRED 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. PZ
PENALTY APPLIED TO PAYMENT DUE TO ADVANCED NOTIFICATION REQUIREMENTS 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 18
DENIED - CERTIFIED LENGTH OF STAY EXCEEDED.
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. KP
PENALTY APPLIED TO PAYMENT DUE TO LACK OF PRE AUTHORIZATION
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 80
PEND-SERVICES/BENEFIT NOT AUTHORIZED BY THE PLAN
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 43 DENIED-NO REFERRAL ON FILE 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 8E
REDUCED PAYMENT-NO REFERRAL RECD-MBR MAY BE BILLED UP TO CONTRACTED RATE 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. UA
PAID AT 50%, NO PRE-AUTHORIZATION RECEIVED.
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 3S
DENIED - SKILLED NURSING FACILITY (NOT AUTHORIZED)
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 1C
PAYMENT REVERSED. NON-REFERRED SERVICES, MEMBER MAY BE BILLED. 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. KS
REDUCED RATE NO REFERRAL RCVD MEMBER MAY BE BILLED CONTRACTED RATE
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. JG
DENIED- SERVICE EXCEEDS PRE-AUTHORIZED LIMIT
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. R5
CHARGES APPLIED TO $200.00 PENALTY FOR LACK OF PRE-CERTIFICATION
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 1R
DENIED-PROC REQUIRES PRE-AUTH. PROVIDER MUST SUBMIT PRE-OPERATIVE NOTES.
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. B4
PENALTY APPLIED TO PAYMENT DUE TO LACK OF PRE-AUTHORIZATION
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 3N DENIED - HOME HEALTH (NOT AUTHORIZED) 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 4D
NO PRIOR AUTH/REFERRAL RECEIVED - MEMBER MAY BE BILLED
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 3V
DENIED-UNAUTHORIZED NON-PARTICIPATING PROVIDER-MEMBER MAY BE BILLED
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 3Z
DENIED - RADIOLOGY PROCEDURE REQUIRED PREAUTH - OUT OF NETWORK PROVIDER 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. F7
DENIED - UNAUTHORIZED NON-PARTICIPATING PROVIDER
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 6E
PAYMENT FOR THIS SERVICE HAS BEEN REDUCED DUE TO NON RECEIPT OF REFERRAL 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 35
DENIED-PRIOR AUTHORIZATION REQUIRED FOR MEDICAL EQUIPMENT/SUPPLIES. 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 45
DENIED - UNAUTHORIZED NON-PARTICIPATING PROVIDER-MEMBER MAY BE BILLED
62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. HP SERVICE EXCEEDS AUTHORIZED DAYS BY ^. 62
Payment denied/reduced for absence of, or
exceeded, pre-certification/authorization. 4B
DENIED - SERVICE EXCEEDS PRE AUTHORIZATION LIMIT
85 Interest amount. OI
PAYMENT WAS DELAYED - INTEREST WAS PAID ON THIS CLAIM
88
Adjustment amount represents collection against
receivable created in prior overpayment. JM PAYMENT DUE APPLIED TO OVERPAYMENT 88
Adjustment amount represents collection against
receivable created in prior overpayment. RM
PAID, USED TO OFFSET OUTSTANDING REFUND REQUEST (L&R)
96 Non-covered charge(s). 27 THE SERVICE IS NO LONGER A BENEFIT.
96 Non-covered charge(s). 74 DENIED-NOT A COVERED BENEFIT
96 Non-covered charge(s). HN THE BENEFIT HAS NOT BEEN PURCHASED.
96 Non-covered charge(s). RG
DENIED-NOT A COVERED BENEFIT UNDER YOUR PLAN
96 Non-covered charge(s). 12 DENIED - PROCEDURE IS NOT COVERED.
96 Non-covered charge(s). MV
DENIED - PROVIDER MUST BILL WITH THE APPROPRIATE ANESTHESIA CODE
96 Non-covered charge(s). 1B DENIED - NOT COVERED UNDER ERISA PLAN
96 Non-covered charge(s). D8 DENIED-NON COVERED DME/SUPPLIES
96 Non-covered charge(s). 26
CONTRACT HAS NOT SELECTED THIS SUPPLEMENTAL MEDICAL RIDER.
96 Non-covered charge(s). NC
NOT A COVERED PROCEDURE - MEMBER CANNOT BE BILLED
96 Non-covered charge(s). 3Q
DENIED - SHOE ORTHOTICS NOT A COVERED BENEFIT
96 Non-covered charge(s). H2
DENIED - PROCEDURE NOT COVERED. MEMBER CANNOT BE BILLED.
96 Non-covered charge(s). JE DENIED-NON COVERED DENTAL SERVICES
96 Non-covered charge(s). FX
THE PROCEDURE MUST BE A MAJOR SURGICAL PROCEDURE
96 Non-covered charge(s). 25
THERE IS NO BASIC OTHER COVERAGE FOR THIS MEDICAL RIDER.
96 Non-covered charge(s). JF
DENIED-NON COVERED ORTHOTICS,DME OR SUPPLIES.
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
96 Non-covered charge(s). 3P
DENIED - ROUTINE FOOT CARE - NOT A COVERED BENEFIT
96 Non-covered charge(s). 3T
DENIED - PERSONAL COMFORT ITEMS - NOT A COVERED BENEFIT
96 Non-covered charge(s). 3J
DENIED - DENTAL SERVICES ARE NOT A COVERED BENEFIT
96 Non-covered charge(s). 3C
NOT A COVERED BENEFIT - MEMBER MAY BE BILLED
96 Non-covered charge(s). 3A
NOT A COVERED BENEFIT - MEMBER CANNOT BE BILLED
96 Non-covered charge(s). R6 NON-COVERED DME/SUPPLIES
96 Non-covered charge(s). JH NON COVERED HANDLING & DRAWING FEE
96 Non-covered charge(s). 34 DENIED-NOT A COVERED BENEFIT
96 Non-covered charge(s). FS
THE PROCEDURE IS NOT A MAJOR SURGICAL PROCEDURE
97
Payment is included in the allowance for another
service/procedure. G3
CC - INFORMATIONAL ONLY, CORRECTED PROC CODE ADDED BY CODING SOFTWARE 97
Payment is included in the allowance for another
service/procedure. 37
PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE
97
Payment is included in the allowance for another
service/procedure. WW
ST RAPHAEL'S HOSPITAL AMBISURG-ANCILLARY'S HISTORY ONLY 97
Payment is included in the allowance for another
service/procedure. M0
ORAL MEDICATIONS/SUPPLIES INCLUDED IN OFFICE VISIT-MEMBER CANNOT BE BILL 97
Payment is included in the allowance for another
service/procedure. Y4
CI - MORE APPROPRIATE PROCEDURE HAS BEEN ADDED
97
Payment is included in the allowance for another
service/procedure. Y3
CI - SERVICE HAS BEEN RECODED BASED ON PREVIOUSLY BILLED SERVICES
97
Payment is included in the allowance for another
service/procedure. YQ
CI - PROCEDURE IS INCLUDED IN PHYSICIAN VISIT SERVICE.
97
Payment is included in the allowance for another
service/procedure. 52
DENIED-THIS PROCEDURE IS CONSIDERED PART OF ANOTHER CPT CODE ON CLAIM. 97
Payment is included in the allowance for another
service/procedure. KM
SVCS ARE INCL IN GLOBAL FEE FOR SOME SURG CODES -MEMBER CANNOT BE BILLED 97
Payment is included in the allowance for another
service/procedure. SF
CC - PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE
97
Payment is included in the allowance for another
service/procedure. 0S
CI-THIS SERVICE IS INCLUDED IN A RELATED PROC BILLED BY SAME PROVIDER
97
Payment is included in the allowance for another
service/procedure. 00 CLAIM LEVEL PRICING DENY
97
Payment is included in the allowance for another
service/procedure. YZ
CI - PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE
97
Payment is included in the allowance for another
service/procedure. J3
CC - PAYMENT FOR SERVICE IS INCLUDED IN GLOBAL SURGICAL FEE
97
Payment is included in the allowance for another
service/procedure. A5 CLAIM CHECK REVIEW
97
Payment is included in the allowance for another
service/procedure. 9B INFO EX FOR REPLACEMENT SERVICES
97
Payment is included in the allowance for another
service/procedure. 9A DENY EX FOR REPLACED SERVICES
97
Payment is included in the allowance for another
service/procedure. 90 HISTORY ONLY
97
Payment is included in the allowance for another
service/procedure. G2
CC - THIS SERVICE IS INCLUDED IN A RELATED PROC BILLED BY SAME PROVIDER
97
Payment is included in the allowance for another
service/procedure. G9
CC - SERVICE AFFECTED BY PROVIDER SPLIT BILLING/RELATED CLAIM
97
Payment is included in the allowance for another
service/procedure. I2
PER CFC IPA,DENIED-INCLUDED IN GLOBAL FEE OF PRIMARY SURGICAL PROCEDURE
97
Payment is included in the allowance for another
service/procedure. VP
MEMBER MAY NOT BE BILLED, SERVICE INCLUDED AS PART OF ROUTINE PAYMENT 97
Payment is included in the allowance for another
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
97
Payment is included in the allowance for another
service/procedure. WA
SERVICE INCLUDED IN GLOBAL AMBULATORY SURGICAL REIMBURSEMENT RATE
97
Payment is included in the allowance for another
service/procedure. 60 ZERO AMOUNT BILLED. HISTORY ONLY.
97
Payment is included in the allowance for another
service/procedure. W9
PAY $0.00-FEE FOR THIS SERVICE IS INCLUDED IN THE PRIMARY PROCEDURE
97
Payment is included in the allowance for another
service/procedure. G7
CC - PROCEDURE REPLACED THROUGH OUR CODING SOFTWARE
100 Payment made to patient/insured/responsible party. MY
PHCS PPO - PREFERRED PAR PROVIDER ALLOWABLE APPLIED. MEMBER NOT LIABLE. 100 Payment made to patient/insured/responsible party. JL
AMOUNT ALLOWED BASED ON PROVIDER'S DISCOUNTED RATE
100 Payment made to patient/insured/responsible party. MU
PAID AT ESTIMATED MEDICARE RATE, ADVISE IF UNACCEPTABLE
100 Payment made to patient/insured/responsible party. 20 FOR REPORTING PURPOSES ONLY. 100 Payment made to patient/insured/responsible party. HC APPROVED BY CASE MANAGEMENT 100 Payment made to patient/insured/responsible party. B7
CLAIM HAS BEEN RECODED FOR THE CORRECT BENEFIT/PRICING
100 Payment made to patient/insured/responsible party. HJ
MEMBER'S ALTERNATE COVERAGE HAS TERMINATED - CONNECTICARE IS PRIMARY 100 Payment made to patient/insured/responsible party. A8
AS OF 03/01/2001 PLEASE CALL 888-946-4658 TO AUTHORIZE THIS SERVICE
100 Payment made to patient/insured/responsible party. T6 CONTRACT YEAR DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. P4
PAY & EDUCATE - INAPPROPRIATE USE OF EMERGENCY ROOM
100 Payment made to patient/insured/responsible party. O1
CALENDAR YEAR OUT-OF-POCKET MAXIMUM HAS BEEN MET.
100 Payment made to patient/insured/responsible party. EQ CLAIM REVERSED DUE TO PARTIAL REFUND. 100 Payment made to patient/insured/responsible party. LS
COPAY OR 20% COINSURANCE, WHICHEVER LESS, APPLIED TO THIS SERVICE
100 Payment made to patient/insured/responsible party. W1 CC - POTENTIAL COB PAY EX CODE 100 Payment made to patient/insured/responsible party. W2 CC - PAY-AUDIT COMPONENT BILLING 100 Payment made to patient/insured/responsible party. EK
CLAIM DENIAL REVERSED DUE TO APPEAL THROUGH EMERGENCY ROOM APPEAL COMM. 100 Payment made to patient/insured/responsible party. EL
CLAIM DENIAL REVERSED DUE TO APPEAL THROUGH GRIEVANCE COMMITTEE. 100 Payment made to patient/insured/responsible party. EM CLAIM DENIAL REVERSED DUE TO APPEAL. 100 Payment made to patient/insured/responsible party. LT EMERGENCY ROOM LETTER SENT TO MEMBER 100 Payment made to patient/insured/responsible party. EP CLAIM REVERSED DUE TO FULL REFUND. 100 Payment made to patient/insured/responsible party. 06
AMT ALLOWED BASED ON PROVIDER'S DISCOUNTED RATE-MEMBER CANNOT BE BILLED
100 Payment made to patient/insured/responsible party. 5B
PEND-IF BILLED W/DENTAL PX*RECODE TO D9220,D9221
100 Payment made to patient/insured/responsible party. MM
MANUALLY PRICED CLAIMS FOR PRO-AMERICA PROVIDERS
100 Payment made to patient/insured/responsible party. OV OVER FILING LIMIT-PROCESSED TO PAY 100 Payment made to patient/insured/responsible party. NY
MANUAL PRICE - NY PROVIDER, PRICING REQUIRED SEE NETWORK OPS FOR RATES
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
100 Payment made to patient/insured/responsible party. LE
CALENDAR YEAR DME DEDUCTIBLE HAS BEEN MET
100 Payment made to patient/insured/responsible party. Q3
AS OF 7/1/2000 PREAUTHORIZATION WILL BE REQUIRED FOR THIS SERVICE.
100 Payment made to patient/insured/responsible party. SZ
FUTURE CLAIMS WITH INCOMPLETE DIAGNOSIS CODES WILL BE DENIED 100 Payment made to patient/insured/responsible party. P3 PAY & EDUCATE - REFERRAL 100 Payment made to patient/insured/responsible party. YU
CI - PAYMENT REDUCED 8% SINCE NON-IONIC CONTRAST WAS USED
100 Payment made to patient/insured/responsible party. 29 MANUALLY PRICED BY CLAIMS SPECIALIST 100 Payment made to patient/insured/responsible party. K9 OUT OF POCKET MAXIMUM HAS BEEN MET 100 Payment made to patient/insured/responsible party. YO
CLAIMS ADJUSTED - PAID INCORRECT FEE - MASS REVERSAL
100 Payment made to patient/insured/responsible party. PR
CLAIMS PENDING FOR PRICING CONFIGURATION IS NOT COMPLETED 100 Payment made to patient/insured/responsible party. OA
NON-REIMBURSABLE CHARGES, DISCOUNT GIVEN AT TIME OF PURCHASE.
100 Payment made to patient/insured/responsible party. YT
CI - SERVICE COUNT HAS BEEN CORRECTED TO ALLOWABLE # OF UNITS
100 Payment made to patient/insured/responsible party. MK
APPEAL PAY & EDUCATE - INNAPPROPRIATE USE OF ER ROOM
100 Payment made to patient/insured/responsible party. T8
CONTRACT YEAR OUT-OF-POCKET MAXIMUM HAS BEEN MET
100 Payment made to patient/insured/responsible party. KA
PAID IN ACCORDANCE W/ MULTIPLAN INC DISCOUNT RATE AGREEMNT
100 Payment made to patient/insured/responsible party. YL
TAX ID AND PROVIDER ID SUBMITTED DO NOT MATCH OUR RECORDS.
100 Payment made to patient/insured/responsible party. HH
MEMBER AGE 65 AND NO MEDICARE COVERAGE ON FILE
100 Payment made to patient/insured/responsible party. YK
DENIED - SERVICE COUNT HAS BEEN CORRECTED TO ALLOWABLE # OF UNITS 100 Payment made to patient/insured/responsible party. YJ EXCLUDED FROM ICM - SEE CLAIM REMARKS 100 Payment made to patient/insured/responsible party. 3B BIRTH TO THREE MEMBER
100 Payment made to patient/insured/responsible party. UC HCFA REQUIREMENT 100 Payment made to patient/insured/responsible party. J7
REPRICED ACCORDING TO UNITED RESOURCE NETWORK CONTRACTUAL AGREEMENT 100 Payment made to patient/insured/responsible party. 21
PRICED PER DISCOUNT UP TO MAXIMUM ALLOWABLE
100 Payment made to patient/insured/responsible party. C2
INFORMATION SUBMITTED ON CLAIM INDICATES POSSIBLE SUBROGATION
100 Payment made to patient/insured/responsible party. HF DIAGNOSIS NOT PRESENT ON AUTHORIZATION 100 Payment made to patient/insured/responsible party. C1 MVA INVESTIGATION
100 Payment made to patient/insured/responsible party. HY
CHP MEMBER - PAID PER SPECIAL ARRANGEMENT
100 Payment made to patient/insured/responsible party. PG
CLAIM PROCESSED USING DRG PRICER GROUPER.
100 Payment made to patient/insured/responsible party. RU
DENIAL REVERSED - PER IPA MEDICAL DIRECTOR
100 Payment made to patient/insured/responsible party. RN
CLAIM DENIAL REVERSED - CASE MANAGER DECISION
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
100 Payment made to patient/insured/responsible party. MQ UP & UP/ AHP CONTRACTUAL ADJUSTMENT 100 Payment made to patient/insured/responsible party. UT
PCP AND MEMBER AGREED UTILIZE CCI NETWORK.
100 Payment made to patient/insured/responsible party. G6 THIS IS A PAYABLE SERVICE. 100 Payment made to patient/insured/responsible party. UJ
POSP 28899 IS NOT APPLICABLE INFORMATIONAL FOR PROVIDER ONLY 100 Payment made to patient/insured/responsible party. G8 CC - FOLD STATUS-INFO ONLY
100 Payment made to patient/insured/responsible party. UH
POSP 28899 - INFORMATIONAL FOR PROVIDER ONLY
100 Payment made to patient/insured/responsible party. Y2
CI - PROCEDURE HAS BEEN REPLACED WITH MORE APPROPRIATE CODE
100 Payment made to patient/insured/responsible party. 2A PAYMENT MUST BE MADE TO THE MEMBER 100 Payment made to patient/insured/responsible party. OC
DENIED-NON-PARTICIPATING PROVIDERS ARE NOT COVERED
100 Payment made to patient/insured/responsible party. KK A REFERRAL IS REQUIRED FOR THIS SERVICE 100 Payment made to patient/insured/responsible party. 09
AMOUNT ALLOWED BASED ON PROVIDER'S CONTRACTED RATE
100 Payment made to patient/insured/responsible party. KG
CLAIM DISCOUNTED PER FEE AGREEMENT THRU ADVANCED FOCUS/JOHN ALDEN LIFE 100 Payment made to patient/insured/responsible party. MX CLAIM PRICED PER MULTIPLAN DISCOUNT 100 Payment made to patient/insured/responsible party. TK PAYMENT OF TAX
100 Payment made to patient/insured/responsible party. RL
CLAIM ADJUSTED DUE TO OVERPAYMENT REFUND (L&R)
100 Payment made to patient/insured/responsible party. Q2
AS OF 7/1/2000 PREAUTHORIZATION WILL BE REQUIRED FOR THIS SERVICE.
100 Payment made to patient/insured/responsible party. D1
THE PAYMENT ALLOWED AMOUNT IS CALCULATED AUTOMATICALLY 100 Payment made to patient/insured/responsible party. RC COB RECOVERY
100 Payment made to patient/insured/responsible party. 86 PROVIDER ACCEPTS ASSIGNMENT. 100 Payment made to patient/insured/responsible party. X2
EMERGENCY/URGENT CARE SERVICES RENDERED.
100 Payment made to patient/insured/responsible party. RA
ST. RAPHAEL'S HEALTH CARE SYSTEM ADJUSTMENT FACTOR PAYMENT 100 Payment made to patient/insured/responsible party. 4E CI - SERVICE IS CORRECTLY CODED 100 Payment made to patient/insured/responsible party. L7
CALENDAR YEAR OUT-OF-POCKET MAXIMUM HAS BEEN MET
100 Payment made to patient/insured/responsible party. R2 PAID AT MAXIMUM ALLOWABLE RATE 100 Payment made to patient/insured/responsible party. LB PAID PER DISCOUNTED LAB RATE 100 Payment made to patient/insured/responsible party. CF
PAID-EXTRA CONTRACTUAL AGREEMENT ON FILE
100 Payment made to patient/insured/responsible party. LF
CALENDAR YEAR DISPOSABLE SUPPLY DEDUCTIBLE HAS BEEN MET
100 Payment made to patient/insured/responsible party. LH
CALENDAR YEAR OSTOMY SUPPLY/EQUIPMENT DEDUCTIBLE HAS BEEN MET
100 Payment made to patient/insured/responsible party. WJ MULTIPLE SURGERY CODE-MANUALLY PRICED 100 Payment made to patient/insured/responsible party. D7 CALENDAR YEAR DEDUCTIBLE HAS BEEN MET
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
100 Payment made to patient/insured/responsible party. W3
CC - INFORMATIONAL ONLY, ORIGINAL CODE SUBMITTED ON CLAIM
100 Payment made to patient/insured/responsible party. 04 MANUALLY PRICED.
100 Payment made to patient/insured/responsible party. 01 PAID ACCORDING TO AMOUNT BILLED 100 Payment made to patient/insured/responsible party. MF
ALLOWED FEE AT 110% OF USUAL TO INCLUDE PRIMARY CARE MANAGEMENT FEE
100 Payment made to patient/insured/responsible party. 02 PRICED AT RELATIVE VALUE SCHEDULE. 100 Payment made to patient/insured/responsible party. MD
CLAIM DENIAL REVERSED - MEDICAL DIRECTOR DECISION
100 Payment made to patient/insured/responsible party. 03
AMOUNT ALLOWED BASED ON PROVIDER'S CONTRACTED FEE SCHEDULE
100 Payment made to patient/insured/responsible party. 6T INFORMATIONAL ONLY 100 Payment made to patient/insured/responsible party. D3
YOUR INDIVIDUAL CALENDAR YEAR DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. 62 IMCC HISTORY DATA 100 Payment made to patient/insured/responsible party. RT
DENIAL REVERSED - PER CCI MEDICAL DIRECTOR
100 Payment made to patient/insured/responsible party. LX SERVICE EXEMPT FROM DEDUCTIBLE 100 Payment made to patient/insured/responsible party. LW
MEMBER RESPONSIBILITY CALCULATION BASED ON TOTAL AMOUNT ALLOWED 100 Payment made to patient/insured/responsible party. VH
VARIABLE RISK WITHHOLD FOR HARTFORD PHO
100 Payment made to patient/insured/responsible party. E8
CLAIM DENIAL REVERSED-REFERRAL REC'D FROM PCP
100 Payment made to patient/insured/responsible party. LV
MEMBER RESPONSIBILITY CALCULATION BASED ON TOTAL AMOUNT BILLED 100 Payment made to patient/insured/responsible party. V8 CONNECTICARE 65 IS PRIMARY CARRIER 100 Payment made to patient/insured/responsible party. 89
PAYMENT HAS BEEN MADE DIRECTLY TO THE IRS.
100 Payment made to patient/insured/responsible party. Y9
CI - BILLED MODIFIER REMOVED-DOESN'T APPLY TO THIS SERVICE
100 Payment made to patient/insured/responsible party. L5 CALENDAR YEAR DEDUCTIBLE HAS BEEN MET 100 Payment made to patient/insured/responsible party. MP AMERICA'S HEALTH PLAN PROVIDER UTILIZED 100 Payment made to patient/insured/responsible party. RP
REFERRAL MODIFIED BY PRIMARY CARE PHYSICIAN.PLEASE CALL PCP FOR INFO. 100 Payment made to patient/insured/responsible party. 6I
CALENDAR YEAR IN-NETWORK OUT-OF-POCKET MAXIMUM HAS BEEN MET.
104 Managed care withholding. VR
VARIABLE RISK WITHHOLD FOR MIDDLESEX PROFESSIONAL SERVICES
104 Managed care withholding. VN
VARIABLE RISK WITHHOLD FOR NEW BRITAIN IPA
104 Managed care withholding. VM
VARIABLE RISK WITHHOLD FOR MANCHESTER/ROCKVILLE 107
Claim/service denied because the related or qualifying claim/service was not previously paid or
identified on this claim. ON
PAYABLE ONLY WHEN BILLED WITH OTHER SERVICES
108
Payment adjusted because rent/purchase
guidelines were not met. KR
DENIED - PER CONTRACT MEMBER HAS REACHED CAPPED RENTAL OPTION FOR DME 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. 92
CONNECTICARE IS NOT THE CARRIER FOR THIS BENEFIT
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. JT
THIS GROUP HAS TERMINATED, SUBMIT ALL CLAIMS TO NEW CARRIER.
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. NU
PLEASE SUBMIT SERVICE TO NEU'S MH/SA CARRIER PER INFO ON MBR'S ID CARD. 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. KE
DENIED - PLEASE SUBMIT THE MEDICARE EXPLANATION OF BENEFITS
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. KD
DENIED - SUBMIT ALL-INCLUSIVE BILL FOR COB PROCESSING
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. KF
DENIED - PLEASE SUBMIT THE OTHER INSURANCE EXPLANATION OF BENEFITS 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. 0B
SEND CLAIMS TO MENTAL HEALTH VENDOR, CALL CONNECTICARE FOR ASSISTANCE 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. 6A
DENIED-NOT PRIMARY CARRIER. SUBMIT TO THIRD PARTY CARRIER.
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. MH
CCI IS NOT THE CARRIER FOR THIS SERVICE/SUBMIT CLAIM TO PATHWISE 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. 51
DENIED-CONNECTICARE NOT PRIMARY CARRIER. SUBMIT TO AUTO INS CARRIER. 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. 66
DENIED-NOT PRIM CARR.SUBMIT TO PARTY RESPONSIBLE FOR THE PERSONAL INJURY 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. 67
DENIED-NOT PRIM CARR.PT SELF-INS $5,000 DUE TO LACK OF NO-FAULT COVERAGE 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. SD
PLEASE SUBMIT SERVICE TO MH/SA CARRIER PER INFO ON MBR'S ID CARD.
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. 6C
PLEASE SUBMIT CLAIM TO PRO AMERICA FOR PRICING
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. V2
PLEASE SUBMIT SERVICE TO CCI'S VISION CARE VENDOR.
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. HQ
DENIED-PRIM PAYOR IS BASIC/MAJ MED PLAN. BOTH EXPLAIN OF BENEFITS NEEDED
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. H9
DENIED-REBILL VISION VENDOR WITH ROUTINE DIAG OR SUBMIT CLINICAL DOC.
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. V4
CLAIM FORWARDED.SEND FUTURE VISION CLAIMS TO ROCKY MOUNT,NORTH CAROLINA. 109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. P7
DENIED - PLEASE SUBMIT LEGIBLE CLINICAL DOCUMENT TO PODIATRIC IPA
109
Claim not covered by this payer/contractor. You
must send the claim to the correct payer/contractor. R3
DENIED SERVICES, SUBMIT TO PHARMACY PLAN
110 Billing date predates service date. JV
SERVICES NOT YET RENDERED. PLEASE RESUBMIT AFTER SERVICES ARE RENDERED.
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
115
Payment adjusted as procedure postponed or
canceled. 11
OBSOLETE PROCEDURE CODE - MEMBER CANNOT BE BILLED
115
Payment adjusted as procedure postponed or
canceled. YX
CI - OBSOLETE PROCEDURE CODE-MEMBER CANNOT BE BILLED
119
Benefit maximum for this time period has been
reached. R4
MAXIMUM NUMBER OF REHABILITATION VISITS PAID FOR THIS CALENDAR YEAR.
119
Benefit maximum for this time period has been
reached. 88
PHYSICAL THERAPY MAXIMUM HAS BEEN MET - MEMBER CANNOT BE BILLED
119
Benefit maximum for this time period has been
reached. 77
BENEFIT MAXIMUM FOR THIS CALENDAR YEAR HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. OE
OSTOMY SUPPLY/EQUIPMENT MAXIMUM FOR CALENDAR YEAR HAS BEEN EXHAUSTED 119
Benefit maximum for this time period has been
reached. 71
CALENDAR YEAR MAXIMUM FOR ANTIGENS EXHAUSTED
119
Benefit maximum for this time period has been
reached. LR
IMPLANT REMOVAL PAYMENT SUBJECT TO $1000.00 YEARLY BENEFIT LIMIT
119
Benefit maximum for this time period has been
reached. 78
BENEFIT MAXIMUM FOR THIS CALENDAR YEAR HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. 7A
DENIED ONLY 1 ROUTINE VISION VISIT IS ALLOWED EVERY 2 YEARS.
119
Benefit maximum for this time period has been
reached. 7C
MAXIMUM REHAB VISITS FOR THIS CONDITION HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. V1 MAXIMUM SKILLED NURSING BENEFIT USED
119
Benefit maximum for this time period has been
reached. 76
BENEFIT MAXIMUM FOR THIS CALENDAR YEAR HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. L9
MAXIMUM HOME HEALTH CARE VISITS PAID FOR THIS CALENDAR YEAR
119
Benefit maximum for this time period has been
reached. 72
CALENDAR YEAR REHAB THERAPY MAXIMUM HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. 7G
DENIED, EYEWEAR MAXIMUM EXHAUSTED FOR THIS 12 MONTH PERIOD
119
Benefit maximum for this time period has been
reached. 7F
DENIED, BENEFIT ALLOWS FOR 2 EYE EXAMS PER 12 MONTH PERIOD
119
Benefit maximum for this time period has been
reached. 7D
EYEWEAR MAXIMUM HAS BEEN EXHAUSTED FOR THIS YEAR
119
Benefit maximum for this time period has been
reached. 7E
VISION BENEFIT FOR THIS YEAR HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. M1
MAXIMUM NUMBER OF SESSIONS USED FOR THIS CALENDAR YEAR
119
Benefit maximum for this time period has been
reached. 87
CHIRO FEE SCHEDULE DAILY MAXIMUM HAS BEEN MET- MEMBER CANNOT BE BILLED 119
Benefit maximum for this time period has been
reached. KL
MAXIMUM BENEFIT HAS BEEN EXHAUSTED FOR THIS BENEFIT PERIOD
119
Benefit maximum for this time period has been
reached. M2
MAXIMUM AMBULANCE BENEFIT HAS BEEN PAID
119
Benefit maximum for this time period has been
reached. 9S
DENIED - BENEFIT LIMITS HAVE BEEN EXCEEDED.
119
Benefit maximum for this time period has been
reached. 1M
DENIED-THIS SERVICE CAN ONLY BE BILLED/PAID ONCE PER MONTH. 119
Benefit maximum for this time period has been
reached. PF
TWO YEAR ALLERGY TESTING MAXIMUM EXHAUSTED
119
Benefit maximum for this time period has been
reached. 33
DENIED-BENEFIT LIMITS HAVE BEEN EXCEEDED
119
Benefit maximum for this time period has been
reached. 8A
DME MAXIMUM FOR THIS CALENDAR YEAR HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. 3K
DENIED - MEMBER HAS EXHAUSTED HEARING AID BENEFIT
119
Benefit maximum for this time period has been
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
119
Benefit maximum for this time period has been
reached. KH
THE 2 CALENDAR YEAR MAXIMUM HAS BEEN MET.
119
Benefit maximum for this time period has been
reached. M6
$300.00 CALENDAR YEAR SUPPLY MAX HAS BEEN MET
119
Benefit maximum for this time period has been
reached. M4
MAXIMUM NUMBER OF IN PATIENT DAYS PAID FOR THIS CALENDAR YEAR
119
Benefit maximum for this time period has been
reached. K3
DENIED BENEFIT MAXIMUM FOR SKILLED NURSING HAS BEEN MET
119
Benefit maximum for this time period has been
reached. 6B
DENIED - EARLY INTERVENTION SERVICES CALENDAR YEAR MAX EXHAUSTED 119
Benefit maximum for this time period has been
reached. 3G
DENIED - INPATIENT PSYCHIATRIC - MEMBER HAS REACHED MAXIMUM BENEFIT
119
Benefit maximum for this time period has been
reached. 79
SKILLED NURSING DAYS FOR BENEFIT PERIOD EXCEEDED.
119
Benefit maximum for this time period has been
reached. 7B
DENIED-LIMIT ONE VISION MAXIMUM PER CONTRACT YEAR
119
Benefit maximum for this time period has been
reached. K2
CALENDAR YEAR CHIRO THERAPY MAXIMUM HAS BEEN EXHAUSTED
119
Benefit maximum for this time period has been
reached. 85
DME SUPPLY MAXIMUM FOR THIS CALENDAR YEAR HAS BEEN EXHAUSTED
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 0U
CI - THIS DIAGNOSIS DOESN'T MATCH THIS PROCEDURE
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 98
CLAIM CANNOT BE ACCEPTED
ELECTRONICALLY.PLEASE RESUBMIT CLAIM ON PAPER.
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 32
CODING NOT WITHIN CONTRACT - MEMBER CANNOT BE BILLED
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. VC
PLEASE RESUBMIT WITH ALLOWABLE ALLERGY SERVICE CPT CODE.
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. YW
CI - PROCEDURE NOT VALID FOR MEMBER'S AGE OR GENDER
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. PA
DENIED - PLEASE RESUBMIT WITH PROVIDER SITE NUMBER.
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 96
ONLY ONE DATE OF SERVICE CAN BE ACCEPTED PER CLAIM LINE.RESUBMIT CLAIM.
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 61
CLAIM COORDINATED WITH PAYMENT MADE BY PRIMARY CARRIER
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. P9
DENIED - PLEASE RESUBMIT WITH APPROPRIATE HCPCS CODE
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. HG
DENIED - PROCEDURE CODE IS NO LONGER VALID.PLEASE CORRECT AND RESUBMIT.
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 69
DENIED-SUBMITTED CLAIM & PRIMARY EXPLANATION OF BENEFITS DO NOT MATCH
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 4G
CI-PROCEDURE IS INCORRECT BASED ON THIS,OR PREVIOUSLY BILLED CLAIMS
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. D9
OBSOLETE DIAGNOSIS CODE - MEMBER CANNOT BE BILLED
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. PD
PLEASE RESUBMIT CLAIM WITH CPT-4/HCPC CODE.
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. Y7
CI - THIS PROCEDURE IS NOT TYPICALLY BILLED FOR THIS DIAGNOSIS
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 4I
CI-DUPLICATE OF A PREVIOUSLY PAID NEW OR SOON TO BE OBSOLETE PROC CODE
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. 0T
CI-SERVICE AT FACILITY LOCATION ISN'T PAYABLE TO MD.FACILITY BILLS THIS
125
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever
appropriate. L3
CANNOT BILL DISCHARGE DAY, PLEASE RE-BILL WITH CORRECTED DAYS
131 Claim specific negotiated discount. 05
AMOUNT ALLOWED BASED ON PROVIDER'S DISCOUNTED RATE
131 Claim specific negotiated discount. UR
PAID IN ACCORDANCE WITH UNITED
RESOURCE NETWORK DISCOUNT AGREEMENT
131 Claim specific negotiated discount. TF
PAID ACCORDING TO ENVISIONCARE ALLIANCE, INC. NEGOTIATED DISCOUNT.
131 Claim specific negotiated discount. TD
PAID IN ACCORDANCE WITH NEGOTIATED TRANSPLANT DISCOUNT.
136
Claim Adjusted. Plan procedures of a prior payer
were not followed. FL CLAIM ADJUSTED
148
Claim/service rejected at this time because information from another provider was not provided
or was insufficient/incomplete. UN
DENIED - PLEASE RESUBMIT WITH APPROPRIATE PROVIDER IDENTIFICATION NUMBER
150
Payment adjusted because the payer deems the information submitted does not support this level of
service. 3M
DENIED - HOME HEALTH (MEMBER NOT HOMEBOUND)
150
Payment adjusted because the payer deems the information submitted does not support this level of
service. 3R
DENIED - SKILLED NURSING FACILITY (CUSTODIAL CARE OR NOT DAILY SNF CARE) 150
Payment adjusted because the payer deems the information submitted does not support this level of
service. 3I
DENIED-CHIRO-DOES NOT MEET BENEFIT CRITERIA FOR CHIROPRATIC COVERAGE 150
Payment adjusted because the payer deems the information submitted does not support this level of
service. WS
DENY-PLEASE RESUBMIT WITH DENTAL HCPCS CODE OR CLINICAL DOCUMENTATION.
150
Payment adjusted because the payer deems the information submitted does not support this level of
service. 3L
DENIED - HOME HEALTH (DOES NOT MEET SKILLED NURSING GUIDELINES)
Adj Code ANSI Claims Adjustment Code Description EX Code ConnectiCare EX Code Description
151
Payment adjusted because the payer deems the information submitted does not support this many
services. YS
CI - BILLED PROCEDURES EXCEEDS NUMBER OF UNITS ALLOWED
151
Payment adjusted because the payer deems the information submitted does not support this many
services. H7
CC - BILLED PROCEDURES EXCEEDS # OF UNITS ALLOWED
151
Payment adjusted because the payer deems the information submitted does not support this many
services. Z9
DENIED - THIS SERVICE CAN BE BILLED / PAID 1 UNIT PER DATE OF SERVICE
A0 Patient refund amount. A6 REIMBURSEMENT FOR COPAY
A1 Claim denied charges. B5
DENIED-NON PARTICIPATING VISION VENDOR PROVIDER-NO BENEFITS ARE PAYABLE.
A2 Contractual adjustment. FE
CLAIM ADJUSTED - INCORRECT DEDUCTIBLE TAKEN.
A2 Contractual adjustment. AO
ADJUSTMENT FACTOR FOR MIDDLESEX PROFESSIONAL SERVICES
A2 Contractual adjustment. ET CLAIM ADJUSTED - SERVICES PAID IN ERROR
A2 Contractual adjustment. FG
VOID CHECK - PAYMENT MADE TO INCORRECT PROVIDER
A2 Contractual adjustment. EU
CLAIM ADJUSTED - INCORRECT DATE OF SERVICES.
A2 Contractual adjustment. 1E CLAIM ADJUSTED PER IPA/ EK
A2 Contractual adjustment. ER
CLAIM ADJUSTED - DENIED IN ERROR DUE TO ELIGIBILITY ISSUE
A2 Contractual adjustment. EV
CLAIM ADJUSTED - PAID INCORRECT NUMBER OF SERVICES.
A2 Contractual adjustment. EG
CLAIM ADJUSTED - PAYMENT MADE TO INCORRECT PROVIDER
A2 Contractual adjustment. EH
CLAIM ADJUSTED - PAYMENT MADE TO INCORRECT MEMBER
A2 Contractual adjustment. FF
CLAIM ADJUSTED - INCORRECT CO-INSURANCE TAKEN.
A2 Contractual adjustment. F8
STATISTICAL CLAIM ADJUSTMENT DUE TO FUND
A2 Contractual adjustment. FD
CLAIM ADJUSTED - INCORRECT CO-PAYMENT TAKEN.
A2 Contractual adjustment. FB
CLAIM ADJUSTED - PAID DUE TO ADDITIONAL INFORMATION RECEIVED FROM MEMBER
A2 Contractual adjustment. EX
CLAIM ADJUSTED - DUE TO CHANGE IN HOSPITAL PER DIEM RATE.
A2 Contractual adjustment. F4 ADJUSTMENT FACTOR PAYMENT
A2 Contractual adjustment. I5
PER CFC IPA, CLAIM ADJUSTED, SERVICES PAID IN ERROR
A2 Contractual adjustment. EZ
CLAIM ADJUSTED - ADDITIONAL CHARGES RECEIVED
A2 Contractual adjustment. EY
CLAIM ADJUSTED - DUE TO CHANGE IN FEE SCHEDULE.
A2 Contractual adjustment. FC
CLAIM ADJUSTED - PAID DUE TO ADDITIONAL INFO RECEIVED FROM PROVIDER.
A2 Contractual adjustment. FA
CLAIM ADJUSTED - PAID - REFERRING PHYSICIAN INFORMATION RECEIVED.
A2 Contractual adjustment. H3
HARTFORD PHYSICIAN HOSPITAL ORGANIZATION ADJUSTMENT FACTOR PAYMENT
A2 Contractual adjustment. ES
CLAIM AD
